We often hear about people "in recovery," but what does it actually take to recover from opioid addiction?

Not dying, first of all, and then time and patience,  says Doug Tieman, a recovering alcoholic who is president and chief executive of Caron Treatment Centers in Wernersville. Caron serves 3,480 people with drug and alcohol addictions a year. Tieman explained Caron's process during our Executive Q&A interview  which appeared in the business section of Sunday's Philadelphia Inquirer.

What causes people to be addicted?

There are certainly genetic predispositions, just like there is for diabetes, cancer and hypertension. I mean I had a really good friend who got cancer, who did nothing that would lead him to have cancer.  He didn't smoke.  He did nothing.  He was a health nut, but he had the genetic predisposition and got it anyway.

There are other people who may have no genetic predisposition, but your lifestyle, if you will, makes it happen.  The same is true with addiction.

We know that there's a predisposition.  We understand the brain chemistry.  People have addiction have a different level of brain chemistry.  However, that can be impacted by lifestyle.  Trauma is one of the biggest ones, and trauma could be anything from physical, emotional, sexual.  It could also be lifestyle.  So, in other words, somebody who had no genetic predisposition, but has an accident and starts taking opioids at an early age because of the accident. That's a trauma that could have an impact on brain chemistry.

So, the two are very important and those are the things we talk about with our patients.  We want them to understand the brain chemistry, but we also want them to understand the environment, lifestyle issues that probably had something to do with it.

What’s the difference between treating people with alcoholism and opioid addictions?

Treatment really requires a couple of big differences.  Number one, the detox for an opioid is more challenging than alcohol.  Being able to manage that in a really good medical way is important.  During detox, many opioid addicts don't even want to stay for it, because it's painful.  It feels lousy.  `If this what I have to do to get better, I don't know if I'm cut out for it.'  That, typically, would not happen for alcoholics.  Number one is just the detox component of it.

Number two is the impact on brain chemistry with opioids is so much more significant than alcohol.  It really has to do with dopamine.  Our bodies make dopamine.  It's what we need to feel good with everything, but our bodies also seek homeostasis [equilibrium].  So, if you have massive intakes of an opioid, it actually destroys the brain's ability to naturally make dopamine.

Oh, I see, because you already have enough dopamine, you don’t need to make more.

Yes, because you are getting it from another source. So, the body just stops making it and it does it pretty quickly. That's why [opioid addicts] hate the whole detox period.  They feel awful.  They feel terrible.

The body can’t come to the rescue with a fresh supply of dopamine to make up for the lack of the opioid.

Not yet — that's the second big challenge.  It will eventually get back to a level of normalcy, but it takes time. And that's the third challenge, time.

How much time?

Months. That's the biggest problem.  The biggest treatment challenge in America today is that most people with an opioid illness don't get nearly enough treatment.  It's not long enough.

Do the medical treatments help, like Suboxone?

There are medicines that will help. For example, Suboxone, that makes you feel not so lousy.  It provides a little bit of the dopamine.  It makes you feel better.  It will give you a little bump.

But doesn’t that, at the same point, delay the return of the body’s ability to produce its own dopamine?

It's a taper. It just takes time. The problems with most treatment today is, number one, is that they don't have the medical capability to do effective detox.  So, patients leave during detox.  Number two is they don't have the kind of medical capability to effectively manage medication-assisted treatment to get you to where you need to be.  Number three is you're not in treatment long enough.  If you don't do those three things well, the outcome is abysmal.  Then as a society, we either blame the person saying, `Geeze, you're a drug addict, it's your fault.'  Or, we look at the treatment center, or treatment program and say, `Geeze, this stuff doesn't work anyway.  Why are we spending any money on it?'

How long does recovery take in general?

For someone with an opioid addiction, we believe we need to monitor a person for a year. Typically, a protocol at Caron might be several months in residential treatment, followed by a variety of things.  It could be sober living.  It could be outpatient. It's a step down where you're not going to have doctors and nurses. Like here, it's a very expensive undertaking, but you could be in a sober living that, possibly, instead of costing a thousand dollars a day for them to have all of this type of care, maybe you're in a place that costs a hundred dollars.  Andt you can now be out in society.

We think it should be managed like a chronic illness.  So, we have monitoring.  We have things like recovery care services where we monitor you daily, and have you check in electronically.  We'll talk to you that way.  We also have programs called My First Year Recovery, where we will, actually, be proactive and reach out to you, your spouse, your sponsor, your therapist, your employer.  We have mandatory urine drug screening so we can see how you're doing.  It's sort of like if you were a diabetic and your blood sugars are black on that day.  We're intervening.  This would be the same with this.  If you're not doing compliance — you have a drink, you've missed a meeting, you've missed an appointment.  We intervene immediately so that you don't go down the tubes again.  That leads to effective treatment.

How can people afford that?

It's expensive. A round of treatment her is $35,000 for a month. If you want to take a look at our patient profile, one of the things that we have established ourselves to be is we want to be a world class facility that people with choices will choose to come here, because they get superior care.  It would be a like a Mayo Clinic, a Cleveland Clinic, an M.D. Anderson.  So, 60 percent of the individuals that come here pay for treatment.  They are people who are looking for the best healthcare they can get. The other will be a combination of probably insurance and charity care.  We gave away this last year $10 million in charity care, most of it in Southeast Pennsylvania, because we want to make sure people in our community have an opportunity for this level of care.

After the $35,000 for a month program, what’s next?

After that, if you went to a Caron program, we can extend you here. We also have a program in Florida that could be another $15,000-$20,000 a month.

So, the whole ball of wax is what?

You could easily spend $75-$100,000 on recovery. Of the people who would follow our regimen we would expect 70 percent to be sober at the end of the year. We'd expect 95 percent of the folks to say life is a lot better.  `Maybe I don't quite have it, but I'm still working at it.'  Again, with any kind of chronic illness, you look for the disease to go in remission.

But, the thing with relapsing on opioids, as you said, it’s such a sudden onset. It’s not like alcoholism, where, perhaps, you could slip in a drink or two without totally losing it.

There's no casual use of this. And, if you relapse, it's significant and profound.  Like, an alcoholic, if they begin to relapse and have two drinks this Saturday, the world probably didn't come to an end.  Maybe they have four drinks next Saturday.  Eventually, unfortunately, it will get there, but it takes time.  Whereas, if the opioid addict decides, `I think I'm going to try some heroin this Saturday,' it's immediate and profound.  When I was talking about those numbers there, that's everything.  All of our substances.  We find that opioids don't have quite the same recovery rate as the general population.  It typically is about five percentage points less.  So, instead of the 70 percent, it was more like 65 percent, which is still very good.  But, if you're being monitored, just like with cancer, diabetes, you continue to work at it.

In summary?

There are two important things that we talk about.  Number one is don't die, which is why Naloxone is important.  Number two is don't stop trying.  If you had cancer, you wouldn't say, `Okay, chemo didn't work.  I guess I won't try anything else.'  You continue to look for the right regimen.